Introduction
Menopause is a stage in a woman’s sexual life that is associated with physical, physiological, and psychological changes and often affects the sexual functions of middle-aged women [1, 2]. Sexual function is an important part of menopausal women’s life and changes in it, especially during menopause, can affect their health. The prevalence of sexual performance problems among all women is estimated between 25 and 63 %. This prevalence in post-menopausal women is even higher and ranges from 68 to 86.5% in different countries [7]. To improve sexual function, there are various psychological methods. Some of the basic approaches to work in the field of sexual knowledge and dysfunctional communication beliefs are cognitive and behavioral therapy (CBT) and acceptance and commitment therapy (ACT) [6, 13]. The aim of this study was to compare the effectiveness of CBT and ACT on the sexual function of postmenopausal women.

Materials and Methods
The current research method was quasi-experimental with a pre-test, post-test, and follow-up with a control group, which was implemented in health centers number 9, 14, and 17 in Zanjan city in 2019-2020. The statistical population of the study included postmenopausal women who had gone through menopause in the past five years and had an undesirable sexual function and were referred to the aforementioned health center in Zanjan from November to January 2019 to receive services. First, the “Female Sexual Function Index” was completed by 70 menopausal women in a targeted manner. Then, of women who scored less than 28 out of 36 in the above index, 45 people were eligible for selection and randomly assigned to three groups of 15 people (intervention 1, intervention 2, and control). The control group did not receive any intervention, while in the first group, the intervention of CBT and in the second group, the intervention of ACT were implemented, each in eight sessions. The “Female Sexual Function Index” questionnaire was used to measure the data. The data obtained from the research were analyzed through analysis of variance with repeated measurements and using SPSS software, version 24.

Results
The mean age of the CBT, ACT, and control groups was 52.20(3.12), 50.40(5.52), and 50.86(1.99) years. Using the ANOVA results, the mean age of the three groups did not differ significantly (P>0.05). Before analyzing the data, its assumptions were examined. The results of the Kolmogorov-Smirnov test for sexual function (P>0.05) indicated that the variables in question were normal. Also, the results of Levene’s and Box’s M tests were not significant (P>0.05). These findings suggest the equality of variances. Therefore, ANOVA with repeated measurements was used.
According to Table 1, the trend of changes in the CBT group compared to the control group in the measurement stages of sexual function variables (F=25.25 and P=0.001) was significantly different (P<0.05) and about 42% of observed differences in sexual function variables were due to group membership (intervention).



According to Table 2, the trend of changes in the ACT group compared to the control group in the stages of measurement in sexual function variables (F=4.186 and P=0.049) was significantly different (P<0.05) and 13% of observed differences in sexual performance variables were due to group membership (intervention). Regarding the intergroup effects, there was no statistically significant difference between the two intervention groups in sexual performance (F=0.004, P=0.952) (P<0.05).



Discussion 
The purpose of this study was to compare the effectiveness of CBT and ACT on the sexual function of postmenopausal women. The results showed that after the intervention and follow-up, the level of sexual function among the intervention groups was significantly different from the control group, and the comparison of the averages also indicated an increasing trend after the implementation of the intervention. In other words, CBT and ACT improved the sexual function of postmenopausal women, and this effect was sustained for three months of follow-up. However, no significant difference was observed between the effectiveness of these two interventions on the sexual function of postmenopausal women. In explaining the results of the current research, it can be said that CBT with an increasing positive exchange, providing information in various fields, including sexual knowledge, changing dysfunctional misconceptions (cognitive distortions), cognitive reconstruction, creating problem-solving skills, and effective interpersonal relationships and negotiation increased the sexual function of postmenopausal women. CBT provides an opportunity for women to learn appropriate ways to identify and correct thoughts and methods of intercourse and sexual satisfaction and cognitive reconstruction to improve sexual disorders [34, 35, 4]. In explaining the effectiveness of ACT on sexual function, the results of many studies have shown that primarily many marital conflicts and dissatisfactions are caused by couples’ behavioral and psychological inflexibility with each other. On the other hand, ACT allows patients to change relationships with inner experiences, reduce experiential avoidance, increase psychological flexibility, and increase activity in a valuable path [41]. Considering that CBT and ACT treatments improved sexual function in postmenopausal women, it is suggested to use these treatments to improve the sexual function of postmenopausal women in health centers. 

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the ethics committee of the Zanjan University of Medical Sciences (Code: IR.ZUMS.REC.1398.328).

Funding
This article is the result of a PhD. student thesis by Rostamkhani Fatemeh in counseling and has not received any financial aid from government, private, or non-profit organizations.

Authors' contributions
All authors contributed equally to preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors sincerely appreciate the research vice-chancellor of Islamic Azad University, Abhar branch, the officials of the University of Medical Sciences and the colleagues of health centers in Zanjan city, and the women who participated in this research.

 

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